Self-application of fluoride by rinsing

Fluoride mouthrinses for preventing dental caries in children and adolescents

BACKGROUND

Fluoride mouthrinses have been used extensively as a caries-preventive intervention in school-based programmes and by individuals at home. This is an update of the Cochrane review of fluoride mouthrinses for preventing dental caries in children and adolescents that was first published in 2003.

OBJECTIVES

The primary objective is to determine the effectiveness and safety of fluoride mouthrinses in preventing dental caries in the child and adolescent population.The secondary objective is to examine whether the effect of fluoride rinses is influenced by:• initial level of caries severity;• background exposure to fluoride in water (or salt), toothpastes or reported fluoride sources other than the study option(s); or• fluoride concentration (ppm F) or frequency of use (times per year).

SEARCH METHODS

We searched the following electronic databases: Cochrane Oral Health's Trials Register (whole database, to 22 April 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2016, Issue 3), MEDLINE Ovid (1946 to 22 April 2016), Embase Ovid (1980 to 22 April 2016), CINAHL EBSCO (the Cumulative Index to Nursing and Allied Health Literature, 1937 to 22 April 2016), LILACS BIREME (Latin American and Caribbean Health Science Information Database, 1982 to 22 April 2016), BBO BIREME (Bibliografia Brasileira de Odontologia; from 1986 to 22 April 2016), Proquest Dissertations and Theses (1861 to 22 April 2016) and Web of Science Conference Proceedings (1990 to 22 April 2016). We undertook a search for ongoing trials on the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the World Health Organization International Clinical Trials Registry Platform. We placed no restrictions on language or date of publication when searching electronic databases. We also searched reference lists of articles and contacted selected authors and manufacturers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials where blind outcome assessment was stated or indicated, comparing fluoride mouthrinse with placebo or no treatment in children up to 16 years of age. Study duration had to be at least one year. The main outcome was caries increment measured by the change in decayed, missing and filled tooth surfaces in permanent teeth (D(M)FS).

DATA COLLECTION AND ANALYSIS

At least two review authors independently performed study selection, data extraction and risk of bias assessment. We contacted study authors for additional information when required. The primary measure of effect was the prevented fraction (PF), that is, the difference in mean caries increments between treatment and control groups expressed as a percentage of the mean increment in the control group. We conducted random-effects meta-analyses where data could be pooled. We examined potential sources of heterogeneity in random-effects metaregression analyses. We collected adverse effects information from the included trials.

MAIN RESULTS

In this review, we included 37 trials involving 15,813 children and adolescents. All trials tested supervised use of fluoride mouthrinse in schools, with two studies also including home use. Almost all children received a fluoride rinse formulated with sodium fluoride (NaF), mostly on either a daily or weekly/fortnightly basis and at two main strengths, 230 or 900 ppm F, respectively. Most studies (28) were at high risk of bias, and nine were at unclear risk of bias.From the 35 trials (15,305 participants) that contributed data on permanent tooth surface for meta-analysis, the D(M)FS pooled PF was 27% (95% confidence interval (CI), 23% to 30%; I(2) = 42%) (moderate quality evidence). We found no significant association between estimates of D(M)FS prevented fractions and baseline caries severity, background exposure to fluorides, rinsing frequency or fluoride concentration in metaregression analyses. A funnel plot of the 35 studies in the D(M)FS PF meta-analysis indicated no relationship between prevented fraction and study precision (no evidence of reporting bias). The pooled estimate of D(M)FT PF was 23% (95% CI, 18% to 29%; I² = 54%), from the 13 trials that contributed data for the permanent teeth meta-analysis (moderate quality evidence).We found limited information concerning possible adverse effects or acceptability of the treatment regimen in the included trials. Three trials incompletely reported data on tooth staining, and one trial incompletely reported information on mucosal irritation/allergic reaction. None of the trials reported on acute adverse symptoms during treatment.

AUTHORS' CONCLUSIONS

This review found that supervised regular use of fluoride mouthrinse by children and adolescents is associated with a large reduction in caries increment in permanent teeth. We are moderately certain of the size of the effect. Most of the evidence evaluated use of fluoride mouthrinse supervised in a school setting, but the findings may be applicable to children in other settings with supervised or unsupervised rinsing, although the size of the caries-preventive effect is less clear. Any future research on fluoride mouthrinses should focus on head-to-head comparisons between different fluoride rinse features or fluoride rinses against other preventive strategies, and should evaluate adverse effects and acceptability.

Caries-preventive effect of sodium fluoride mouthrinses: a systematic review of controlled clinical trials

The Swedish Council on Technology Assessment in Health Care launched a project group in 1999 to systematically review and evaluate the existing literature on different caries-preventive methods. The aim of this article was to report the findings concerning the caries-preventive effect of fluoride mouthrinses (FMRs) in various age groups, with special reference to background fluorides. A systematic search in electronic databases for literature published between 1966 and August 2003 was conducted with the inclusion criteria of a randomized or controlled clinical trial, at least 2 years' follow-up, and caries increment in the permanent dentition (DeltaDMFS/T) as endpoint. Out of 174 articles originally identified, 62 met the inclusion criteria. These studies were assessed independently by at least two reviewers and scored A-C according to predetermined criteria for methodology and performance. The measure of effect was the prevented fraction (PF) expressed as percent. The level of evidence was based on 25 articles. The results revealed limited evidence (evidence level 3) for the caries-preventive effect (PF 29%) of daily or weekly sodium fluoride rinses compared with placebo in permanent teeth of schoolchildren and adolescents with no additional fluoride exposure and for a caries-preventive effect on root caries in older adults. Inconclusive evidence (evidence level 4) was found regarding the effect of FMRs in schoolchildren and adolescents exposed to additional fluoride sources such as daily use of fluoride toothpaste. No firm support for the use of FMRs was disclosed in a small number of studies designed for patients at caries risk. Furthermore, no association between the frequency of the rinses and prevented fraction or saved surfaces per year was found. In conclusion, this systematic review suggests that sodium fluoride mouthrinses may have an anti-caries effect in children with limited background of fluoride exposure, while its additional effect in children with daily use of fluoride toothpaste could be questioned. The need for further clinical trials to elucidate the effect of FMRs in risk patients and older adults is emphasized.

Topical fluoride (toothpastes, mouthrinses, gels or varnishes) for preventing dental caries in children and adolescents

BACKGROUND

Topical fluoride therapy (TFT) in the form of varnish, gel, mouthrinse or toothpaste has been used extensively as a caries-preventive intervention for over three decades.

OBJECTIVES

To determine the effectiveness and safety of fluoride varnishes, gels, mouthrinses, and toothpastes in the prevention of dental caries in children and to examine factors potentially modifying their effect.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register (May 2000), CENTRAL (The Cochrane Library Issue 2, 2000), MEDLINE (1966 to January 2000), plus several other databases. We handsearched journals, reference lists of articles and contacted selected authors and manufacturers.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials with blind outcome assessment, comparing fluoride varnish, gel, mouthrinse, or toothpaste with placebo or no treatment in children up to 16 years during at least 1 year. The main outcome was caries increment measured by the change in decayed, missing and filled tooth surfaces (D(M)FS).

DATA COLLECTION AND ANALYSIS

Inclusion decisions, quality assessment and data extraction were duplicated in a random sample of one third of studies, and consensus achieved by discussion or a third party. Authors were contacted for missing data. The primary measure of effect was the prevented fraction (PF) that is the difference in mean caries increments between the treatment and control groups expressed as a percentage of the mean increment in the control group. Random effects meta-analyses were performed where data could be pooled. Potential sources of heterogeneity were examined in random effects metaregression analyses.

MAIN RESULTS

There were 144 studies included. For the 133 that contributed data for meta-analysis (involving 65,169 children) the D(M)FS pooled prevented fraction estimate was 26% (95% CI, 24% to 29%; p < 0.0001). There was substantial heterogeneity, confirmed statistically (p < 0.0001), but the direction of effect was consistent. The effect of topical fluoride varied according to type of control group used, type of TFT used, mode/setting of TFT use, initial caries levels and intensity of TFT application, but was not influenced by exposure to water fluoridation or other fluoride sources. D(M)FS PF was on average 14% (95% CI, 5% to 23%; p = 0.002) higher in non-placebo controlled trials, 14% (95% CI, 2% to 26%; p = 0.25) higher in fluoride varnish trials compared with all others, and 10% (95% CI, -17% to -3%; p = 0.003) lower in trials of unsupervised home use compared with self applied supervised and operator-applied. There was a 0.7% increase in the PF per unit increase in baseline caries (95% CI, 0.2% to 1.2%; p = 0.004).

REVIEWER'S CONCLUSIONS

The benefits of topical fluorides have been firmly established on a sizeable body of evidence from randomized controlled trials. While the formal examination of sources of heterogeneity between studies has been important in the overall conclusions reached, these should be interpreted with caution. We were unable to reach definite conclusions about any adverse effects that might result from the use of topical fluorides, because data reported in the trials are scarce.

Fluoride mouthrinses for preventing dental caries in children and adolescents

BACKGROUND

Fluoride mouthrinses have been used extensively as a caries-preventive intervention in school-based programmes and individually at home.

OBJECTIVES

To determine the effectiveness and safety of fluoride mouthrinses in the prevention of dental caries in children and to examine factors potentially modifying their effect.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register (May 2000), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2000), MEDLINE (1966 to January 2000), plus several other databases. We handsearched journals, reference lists of articles and contacted selected authors and manufacturers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials with blind outcome assessment, comparing fluoride mouthrinse with placebo or no treatment in children up to 16 years during at least 1 year. The main outcome was caries increment measured by the change in decayed, missing and filled tooth surfaces (D(M)FS).

DATA COLLECTION AND ANALYSIS

Inclusion decisions, quality assessment and data extraction were duplicated in a random sample of one third of studies, and consensus achieved by discussion or a third party. Authors were contacted for missing data. The primary measure of effect was the prevented fraction (PF) that is the difference in mean caries increments between the treatment and control groups expressed as a percentage of the mean increment in the control group. Random effects meta-analyses were performed where data could be pooled. Potential sources of heterogeneity were examined in random effects metaregression analyses.

MAIN RESULTS

Thirty-six studies were included. For the 34 that contributed data for meta-analysis (involving 14,600 children) the D(M)FS pooled PF was 26% (95% confidence interval (CI), 23% to 30%; p < 0.0001). Heterogeneity was not substantial, but confirmed statistically (p = 0.008). No significant association between estimates of D(M)FS prevented fractions and baseline caries severity, background exposure to fluorides, rinsing frequency and fluoride concentration was found in metaregression analyses. A funnel plot of the 34 studies indicated no relationship between prevented fraction and study precision. There is little information concerning possible adverse effects or acceptability of treatment in the included trials.

REVIEWER'S CONCLUSIONS

This review suggests that the supervised regular use of fluoride mouthrinse at two main strengths and rinsing frequencies is associated with a clear reduction in caries increment in children. In populations with caries increment of 0.25 D(M)FS per year, 16 children will need to use a fluoride mouthrinse (rather than a non-fluoride rinse) to avoid one D(M)FS; in populations with a caries increment of 2.14 D(M)FS per year, 2 children will need to rinse to avoid one D(M)FS. There is a need for complete reporting of side effects and acceptability data in fluoride mouthrinse trials.

Effectiveness of mouthrinsing with fluoride solutions in preventing coronal and root caries

Fluoride mouthrinses have been used extensively for the past 15 years to prevent dental caries in children. Their use has been especially widespread in organized school-based programs in the US. Nearly three dozen clinical studies of fluoride mouthrinses, both with and without placebo controls, have been reported in the literature since the early 1960s. The overwhelming majority of those studies report statistically significant caries inhibition from the use of the products. Most of the studies were published prior to the knowledge of a decline in caries prevalence during the past 30 years. Consequently, the results of those studies lacking a placebo control group have been challenged. Even randomized clinical trials with appropriate control groups appear to be reporting declining differences between test and control groups. Using a model based on annual caries increments from published studies, the conclusion is reached that future use of fluoride mouthrinses is unlikely to result in annual savings in DMF increment greater than 0.4 surfaces, regardless of age of rinsers.

[Comparative study of the effect of a .5% NaF solution by mouthwash, toothbrushing or both, in the prevention of dental caries]

Foi realizado estudo a fim de comparar o efeito na redução do ataque de cárie de uma solução de fluoreto de sódio, na concentração de 0,5% aplicada sob a forma de bochecho, escovação, escovação e bochecho, uma vez por semana, sob supervisão, durante um período escolar de 10 meses em 424 escolares de 9 a 10 anos de idade matriculados em cinco escolas estaduais do Estado de São Paulo (Brasil). As crianças foram distribuídas igualmente em três grupos experimentais e um grupo controle, de acordo com a idade dental (nº de superfícies de dentes permanentes irrompidas) e experiência anterior de cárie (CPO-S). Foram examinadas 307 crianças e os resultados mostraram que houve uma redução, estatisticamente significante ao nível de 0,05, de ataque de cárie entre os grupos experimentais e controle, da ordem de 35,19% para o grupo de bochecho (grupo I), de 37,91% para o grupo de escovação (grupo II), e de 49,77% para o grupo de escovação e bochecho (grupo IV). Quando comparados os grupos experimentais entre si não houve diferenças estatisticamente significantes ao nível de 0,05.

Attitudes of health professionals involved in a school-based fluoride mouthrinse program

A study was carried out to assess the attitudes of public health officials and dentists toward a school-based fluoride mouthrinse program administered in grades one through six in Kentucky. The responses were obtained by administering a questionnaire to health officials and dentists. The responses of the health directors indicate support for the program as a means of improving the overall dental care of children. These individuals do not feel a need for direct involvement in the daily operation of the program. They believe that adequately trained school personnel can implement the program. Dentists also view the fluoride mouthrinse program as an effective means of improving children's dental health. However, they feel that it should be part of a broad scope program which includes public health measures. Dentists are reluctant to support a program which they view as increasing the role of government in providing health care.